Why is Asperger Syndrome poorly recognised in France?

Question

Asperger Syndrome is quite well-known in psychiatric circles, as well as (to a lesser degree) the general public, in many countries the western world. However, in France, Asperger Syndrome is virtually unknown to the general public. From what I have read in various sources, French psychiatry denies the existence of Asperger Syndrome, instead using alternative diagnoses and alternative treatments, some of which can be very harmful. This is not the case in other Francophone areas; the situation in Belgium, Quebec and Switzerland is better.

Below I quote the French Wikipedia article on Asperger Syndrome and I attempt to provide a translation:

Le syndrome eut du mal à être reconnu et ne l'est pas encore totalement. Il peut être ignoré par les professionnels, parfois réticents à annoncer le diagnostic à cause d'orientations théoriques personnelles ; le syndrome d'Asperger n'existe pas en tant qu'entité distincte dans les précédentes versions de la CFTMEA et n'y a été individualisé que dans la dernière version (année 2000). Notons que les termes « disharmonie de développement », « disharmonie d'évolution », « disharmonie évolutive », « disharmonie psychotique », « Trouble Complexe et Multiple du Développement (MCDD Multiple-complex Developpemental Disorder) » sont souvent utilisés en France pour décrire les troubles autistiques. Ces termes ne figurent pas dans la nomenclature internationale CIM1014 et ne devraient plus être utilisés, selon les recommandations. De fait, depuis quelques années, certaines associations dénoncent des diagnostics de « dépression infantile » qui sont de plus en plus souvent prononcés à tort, en lieu et place des anciennes « disharmonies »15[réf. insuffisante].

L'approche française se défait néanmoins progressivement d'une imprégnation psychanalytique qui propose une prise en charge singulière du diagnostic et de la prise en charge de ce syndrome.

My rough translation attempt (a native speaker is encouraged to improve):

The syndrome was difficult to be recognized and is still not fully. It can be ignored by professionals who may be reluctant to perform an Asperger diagnosis diagnosis because of personal theoretical opinions; Asperger syndrome does not exist as a separate entity in previous versions of the CFTMEA and was taken up as a separate entity only in the latest version (2000). Note that the terms "disharmonic development," "disharmony of evolution", "progressive disharmony", "psychotic disharmony", "Disorder and Multiple Complex Development (TSLS Multiple-complex Developmental Disorder)" are often used in France to describe autistic disorder. These terms are not included in the international nomenclature CIM1014 and should not be used as recommended. In fact, in recent years, some associations decry diagnostics of "childhood depression" that is increasingly often given erroneously, instead of the former "disharmony".

The French approach however defeats slowly a psychoanalytic penetration that proposes to take a unique diagnosis approach to take care of the syndrome.

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Why is Asperger Syndrome so poorly recognised in France? Are there political reasons behind this (we don't want this "American" thing), does it reflect a wider culture in French psychiatry, or is there no clear cause for this?

Answer 1

I am by no means any sort of expert at the French mental health system, but I was curious and found a few reasons that may indicate why such a philosophy is prevalent.

In this blog, an American psychologist analyzes the differences between the American and French schools of thought on ADHD, but the observations hold for other conditions as well. While Asperger's and ASD aren't necessarily part of the traditional psychiatric clusters, their treatment is often allocated to psychiatrists in the U.S.

From a pragmatic perspective, the very basis for diagnosis for children in France is not based on the DSM as it is in America, the French developed their own manual for diagnosis in children:

They do not use the Diagnostic and Statistical Manual of Mental Disorders or DSM.According to Sociologist Manuel Vallee, the French Federation of Psychiatry developed an alternative classification system as a resistance to the influence of the DSM-3. This alternative was the CFTMEA (Classification Française des Troubles Mentaux de L'Enfant et de L'Adolescent), first released in 1983, and updated in 1988 and 2000.

More importantly, as the article points out, psychiatric disorders are treated more from a psychosocial perspective, rather than a physiological or pharmacological one. That's not to say this is wrong, but it's drastically different in taking cues from a child's social situation/"maladjustment" rather than trying to attribute a psychiatric cause to the condition.

It seems as though the French psychiatric/psychological community is likely to allocate the actual medical bases of these and other disorders to the (non-psychiatric) medical community:

A general comment regarding the French mental health system is that the distinction between the social and the medical components of care is too often unclear, and the management of social problems is frequently delegated to medical institutions and professionals.

So, while the French psychiatric community may be less likely to recognize Asperger's, it may be that the neurological or educational communities may view it in the same light that American's do. Certainly, I would assume that those psychiatrists more steeped in experimental methods and treatments would have some understanding of the neuroanatomical advances that are being made in autism spectrum disorders, so the beliefs you outline in the quote may not be universal.

Also from a practical perspective, because of the philosophy of treating many of these conditions from a psychosocial perspective, there aren't a lot of resources allocated to child psychiatric patients. While a patient with Asperger's is no more or less likely to be hospitalized as another, the overall trend seems to indicate the resources dedicated to outpatient practitioners may be as scarce as those for inpatients (and from the article, does seem to have a much higher density in Southern France and metropolitan areas):

The number of child and adolescent psychiatric beds is relatively low (0.19 beds per 1000 inhabitants) and a large number of sectors (n=182) have no child and adolescent beds at all...not driven by the pressure of cutting costs. It was decided upon by child psychiatrists who thought the the hospitalisation of children could be replaced by day hospitalisation and community psychiatry.

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Reference:

MENTAL, O. O. (2003). Focus on psychiatry in France. BRITISH JOURNAL OF PSYCHIATRY, 183, 466-471.[DOI] [Free PDF]

Answer 2

One thing that is important to understand is that part of what qualifies someone for having a psychological disorder is that their condition is maladaptive to their environment. France has a different culture, or in other words, a different environment than the USA. I have studied french for 8+ years, and while I have not (yet) had the opportunity to go there in person, I can tell you from what I have picked up about French culture that most French people behave in a way that, if they were American, might make you think they were somewhere on the spectrum. That said, I believe that a person with Aspergers would be be able to get by socially more easily in France than in the US. This may be in part the reason that there seems to be less of a presence of Aspergers in France than in the USA and perhaps other countries.

As for the whole "we don't want this "American" thing" attitude that you were talking about, I like to think this sort of aversive attitude toward other cultures is less present among scientists than the general public, but even scientists are only human, and with the French, they can be aversive to a lot of things. More importantly, as I touched upon in the last paragraph, Psychology does not transfer as well across cultures as the cold-hard sciences (because it is a social science, and therefore can vary from one society to another), so the French also have practical reasons for hesitating to take American psychology as their own.

Still, it is rather unusual how so many Western cultures clearly recognize Aspergers and France stands out as not doing so. The other reason this is odd is that Asperger's and Autism in general are known to have a strong genetic basis, so they do have basis in the hard sciences. Still more, whether or not Asperger's is genetically-based (it is) does not change the fact that I brought up in the first paragraph which is that it can be more or less maladaptive from one culture to another.

I hope this helps!

Sources: - 8+ years of studying French (language and culture) - I'm a Psychology major :)